New York State seal

October 2, 1989

SUBJECT: INSURANCE

WITHDRAWN

Circular Letter No. 14 (1989)

TO: AUTOMOBILE SELF-INSURERS AND INSURERS LICENSED TO WRITE AUTOMOBILE INSURANCE IN NEW YORK STATE

RE: NO-FAULT REIMBURSI74ENT SCHEDULES FOR HOSPITAL

(A) INPATIENT SERVICES RENDERED ON AND AFTER JANUARY 1, 1986; AND

(B) INPATIENT SERVICES RENDERED ON AND AFTER JANUARY 1, 1987

Pursuant to Regulation No. 83, 11 NYCRR 68.2; the no-fault rate schedules' for reimbursing hospital services provided under § 5102(a)(1) of Ahe Insurance Law shall be those established, for workers' compensation by the Chair of the Workers' Compensation Board (WCB). These rates have now been established for hospital inpatient services in conformity with Chapter 767 of the Laws of 1977, as amended and § 2807-a of the Public Health Law; as amended.

Attached are two rate schedules duly established by. the WCB Chair:

(a) the first revised per diem schedule to. reimburse hospitals for inpatient services rendered during the period January 1, 1986' through December 31, 1986.

(b) the second per diem schedule to reimburse hospitals for inpatient services, rendered during the period January 1, 1987 through December 31, 1987.

Please note that the Health Department has determined that inpatient hospital admissions prior to January 1, 1988 shall be reimbursed on a per diem basis, rather than by the Diagnosis-Related Group (DRG) approach, effective January 1, 1988 for inpatient reimbursement as discussed in Circular Letter Nos..11 and 18 (1988).

Very truly yours,

[SIGNATURE]

James P. Corcoran

Superintendent of Insurance

TO: Medical Fee Schedule Users

Subject: Amendments to September 1986 Medical Fee Schedule

Attached are amendments to the September 1986 Workers' Compen- sation Board Schedule of Medical Fees. The amendments to the Medical Fee. Schedule, which include changes in Dollar Conversion Factors, apply to Medical, Physical Therapy and Occupational Therapy services rendered on or after September 1, 1989.

For services rendered prior to September 1, 1989, please refer to previously issued material.

NOTE: Effective 1-1-89, the fees listed in this schedule are applicable to services rendered under the Volunteer Ambulance Workers' Benefit Law.

Barbara Patton

Chairwoman

CONVERSION FACTORS

This schedule is divided into seven sections, each containing a coded listing of procedures pertinent to the section, with unit values assigned on a relativity basis to each section therein. The relativity within any one section is applicable to that particular section only. Familiarize yourself with the instructions preceding each section. In submitting reports and bills, list the 5 digit code(s) that identifies the service(s) performed (it is not necessary to describe the service if the 5 digit code is enumerated).

BILLING: The unit values reflect relativity, not fees. To determine the fee for a procedure, it is necessary to multiply the unit value of each procedure by the dollar conversion factor applicable to the particular section in effect on the date the service was rendered.

The Chairman has established four regions within New York State based on the difference in cost of maintaining a medical practice in different localities of the State. The Chairman has defined each such region by use of the U.S. Postal Service Zip Codes for the State of New York, based upon the relative cost factors which are compatible with that region.

The fees payable for medical care and treatment shall be determined by the Region in which the services were rendered.

REGIONAL CONVERSION FACTORS - effective September 1, 1986

 

SECTIONS

REGION 1

REGION 2

REGION 3

REGION 4

 

Medicine

$ 4.88

$ 5.11

$ 5.85

$ 6.36

 

Physical Therapy

4.30

4.51

5.16

5.61

 

Anesthesia

16.74

17.52

20.05

21.81

 

Surgery

123.66

129.42

148.12

161.00

 

Radiology

31.35

32.82

37.55

40.82

 

Pathology

.76

.80

.91

1.00

 

REGIONAL CONVERSION FACTORS - effective September 1, 1987

 

SECTIONS

REGION 1

REGION 2

REGION 3

REGION 4

 

Medicine

$ 5.10

$ 5.35

$ 6.12

$ 6.65

 

Physical Therapy

4.61

4.83

5.53

6.01

 

Anesthesia

17.51

18.33

20.97

22.81

 

Surgery

129.35

135.37

154.93

168.41

 

Radiology

32.79

3433

39.28

42.70

 

Pathology

.79

.84

.95

1.05

 

REGIONAL CONVERSION FACTORS - effective September 1, 1988

 

SECTIONS

REGION 1

REGION 2

REGION 3

REGION 4

 

Medicine

$ 5.39

$ 5.65

$ 6.46

$ 7.02

 

Physical Therapy

4.82

5.05

5.78

6.29

 

Occupational Therapy

4.82

5.05

5.78

6.29

 

Anesthesia

18.49

19.36

22.14

24.09

 

Surgery

136.59

142.95

163.61

177.84

 

Radiology

34.63

36.25

41.48

45.09

 

Pathology

.83

.89

1.00

1.11

 

REGIONAL CONVERSION FACTORS - effective September 1, 1989

SECTIONS

REGION 1

REGION 2

REGION 3

Medicine,

$ 5.71

$ 5.98

$ 6.84

Physical Therapy

5.10

5.35

6.12

Occupational Therapy

5.10

5.35

6.12

Anesthesia

19.58

20.50

23.45

Surgery

144.65

151.38

173.26

Radiology

36.67

38.39

43.93

Pathology

.88

.94

1.06

POSTAL ZIP CODES INCLUDED IN EACH REGION

                 
 

Region I

   

Region II

   

Region IV

 

From,

 

Thru

From

 

Thru

From

 

Thru

12007

 

12099

12180

 

12183

10001

 

10099

12106

 

12177

12201

 

12257

10301

 

10314

12184

 

12199

12301

 

12345

10401

 

10475

12401

 

12498

12501

 

12594

11001

 

11050

12701

 

12792

12601

 

12614

11101

 

11111

                 

12801

 

12887

13201

 

13260

11201

 

11252

12901

 

12998

13440

   

11301

 

11390

13020

 

13094

13501

 

13503

11401

 

11460

13101

 

13167

13901

 

13905

11501

 

11598

13301

 

13368

14201

 

14265

11601

 

11697

                 

13401

 

13439

14601

 

14692

11701

 

11798

13441

 

13495

     

11801

 

11819

13601

 

13698

           

13730

 

13797

           

13801

 

13865

           
       

Region III

       
     

From

 

Thru

     

14001

 

14098

10501

 

10598

     

14101

 

14174

10601

 

10650

     

14301

 

14305

10701

 

10710

     

14410

 

14489

10801

 

10805

     

14501

 

14592

10901

 

10998

     
                 

14701

 

14788

11901

 

11980

     

14801

 

14898

           

14901

 

14905

           

NUMERICAL LIST OF POSTAL ZIP CODES

           

From

Thru

Region

From

Thru

Region

           

10001

10099

IV

12601

12614

II

10301

10314

IV

12701

12792

I

10401

10475

IV

12801

12887

I

10501

10598

III

12901

12998

I

10601

10650

III

13020

13094

I

           

10701

10710

III

13101

13176

I

10801

10805

III

13201

13260

II

10901

10998

III

13301

13368

I

11001

11050

IV

13401

13439

I

11101

11111

IV

13440

 

II

           

11201

11252

IV

13441

13495

I

11301

11390

IV

13501

13503

II

11401

11460

IV

13601

13698

I

11501

11598

IV

13730

13797

I

11601

11697

IV

13801

13865

I

           

11701

11798

IV

13901

13905

II

11801

11819

IV

14001

14098

I

11901

11980

III

14101

14174

I

12007

12099

I

14201

14265

II

12106

12177

I

14301

14305

I

           

12180

12183

II

14410

14489

I

12184

12199

I

14501

14592

I

12201

12257

II

14601

14692

II

12301

12345

II

14701

14788

I

12401

12498

I

14801

14898

I

12501

12594

II

14901

14905

I

MEDICINE

The relative values listed in this section have been determined on an entirely different basis than those in other sections. A conversion factor applicable to this section is not applicable to any other section.

The unit values listed in this section reflect the relativity of charges for procedures within this section only.

The fee for a particular procedure or service in this section is determined by multiplying the listed "unit value" by the current dollar "conversion factor" applicable to this section, subject to the Ground Rules, Instructions and Definitions of the Schedule.

MEDICINE GROUND RULES

General information and Instructions

1. GENERAL: Visits, examinations, consultations and similar services as listed in this section reflect the wide variations in time and skills required in the diagnosis and treatment of illness or injury. The listed relativities apply only when these services are performed by or under the responsible and direct supervision of a physician unless otherwise stated.

2. Specialists rendering services outside their field of specialization as designated by Workers' Compensation Board Coding may charge only general practitioner fees. A specialist shall be paid a specialist's fee only if the injuries sustained or the services rendered are within the scope of his specialty and the services of specialists are indicated or required. (See page 6 for specialist codings and scope restrictions.)

3. Fees indicated for examinations or visits by specialists are payable only to specialists with "C" ratings. Physicians with specialty ratings such as "IM,S" etc., (without the "C" prefix) shall be paid three-quarters of the fee indicated as payable to a specialist with a "C" rating for an office, home or hospital call, but in no event shall the fee for a physician with such a specialty rating be less than the fee payable to a general practitioner for the same service. (See also comprehensive level of service, page 4.)

4. If a patient is referred by a physician to a specialist for an opinion on diagnosis, prognosis, necessity and type of treatment, and such written opinion is sent to the referring physician, the insurance carrier, and the Workers' Compensation Board, a fee shall be payable for such opinion and examination in accordance with the level of service (see definitions), regardless of whether or not the specialist subsequently operates upon or treats the patient. See Ground Rule 20 below.

5. If a patient consults a specialist directly (non-referred case) and a complete examination is necessary for diagnosis, prognosis, necessity and type of treatment, and the specialist submits a report thereon to the Workers' Compensation Board and to the insurance carrier, in addition to or on the regular C-4/C-48 form, a specialist's fee is payable in accordance with the level of service (see definitions), regardless of whether or not the specialist subsequently operates upon or treats the patient.

6. A fee is payable to a specialist, in accordance with the level of service, for the examination of a patient who seeks the care of a physician either directly or by referral from another physician, in instances of elective surgery or when it is incumbent upon the specialist to examine the patient in order to make a proper diagnosis, prognosis and to decide on the necessity and type of treatment to be rendered. This fee is in addition to the unit fee prescribed for the operation or treatment subsequently rendered by the specialist except that where the therapeutic procedure or treatment is of a minor character and the fee for the procedure or treatment is in excess of the fee for the office visit, the greater fee (not both fees) is payable. Similarly, if the fee for the minor procedure or treatment is less than the fee for the office visit, the fee for the office visit alone is payable.

7. Where a physician renders treatment in the EMERGENCY ROOM of a hospital as an individual or as a member of a group under contract with the hospital, including those physicians who are hospital salaried or employed, all such services shall be paid at the general practice rates.

Where a physician enters into an agreement to cover the emergency room of a hospital on a fee-for-service basis, and is not under contract or salaried by the hospital, such physician shall be paid the fees of a general practitioner for the services rendered under the appropriate office visit category.

The above applies to all physicians regardless of specialty coding except for those physicians coded C-EM (Board Certified in Emergency Medicine) or EM (Board-eligible). C-EM's or EM's practicing under a fee-for-service agreement with a hospital shall be paid fees as set forth in the Specialist Fees section, office visits (see page 17). However, C-EM or EM remuneration shall not be at a level of reimbursement above the intermediate level with the exception of treatment of a substantiated life or limb threatening situation when the comprehensive level of service may be applicable. Consultation fees do not apply to C-EMs.

   

Unit

   

Value

90620

A comprehensive consultation involves an

 
 

indepth evaluation of a patient with a problem

 
 

requiring the development and documentation of

 
 

medical data (the chief complaints, present

 
 

illness, family history, past medical history,

 
 

personal history, system review and physical

 
 

examination, review of all diagnostic tests and

 
 

procedures that have previously been done), the

 
 

establishment or verification of a plan for

 
 

further investigative and/or therapeutic

 
 

management and the preparation of a report. For

 
 

example: A young person with fever, arthritis,

 
 

and anemia; or a comprehensive psychiatric

 
 

consultation that may include a detailed

 
 

present illness history, past history, a mental

 
 

status examination, exchange of information

 
 

with primary physician or nursing personnel or

 
 

family members and other informants, and

 
 

preparation of a report with recommendations;

 
 

or a neurological evaluation for possible

 
 

intracranial pathology; or the in-depth

 
 

evaluation for spinal cord pathology

 
 

or a chronic back disorder

22.0

SUBSEQUENT CONSULTATIONS

   
   

Unit

 
   

Value

 

90640

Brief consultative follow-up visit

3.5

 

90641

Limited consultative follow-up visit

6.0

 

90642

Intermediate consultative follow-up visit and

   
 

evaluation

8.5

 

IMMUNIZATION AND THERAPEUTIC

INJECTIONS

(For allergy testing, see 95000 et seq) (For skin testing of bacterial, viral, fungal extracts see 86400-86585)

These injections are usually given in conjunction with a medical service. The unit value for the appropriate medical service will be added to the unit values for the type of injection administered. The cost of the medication or material injected is also additional in accordance with Ground Rule 13; specify material.

   

Unit

   

Value

90745

Injection, subcutaneous

0.0

 

No additional other than the cost of the specified

 
 

injectant

 
     

90746

Intramuscular or deep structures

0.83

90747

Intravenous

3.42

90798

Intravenous therapy for severe or intractable

 
 

allergic disease in physician's office or institution

 
 

(eg. theophyllines, corticosteroids,

 
 

antihistamines)

BR

90799

Unlisted therapeutic injection

BR

PSYCHIATRIC SERVICES

Medical services may be described as coded and listed in other segments in the Medicine Section as appropriate. For initial office or hospital visit see 90010-90020; for subsequent office or hospital visit see 90040-90060; for consultations see 90600-90642. For diagnostic services performed in hospital emergency rooms, Hospital care by the attending physician in treating a psychiatric inpatient may be initial or subsequent in nature, and may include exchanges with nursing and ancillary personnel. Hospital care services involve a variety of responsibilities unique to the medical management of inpatients, such as physician hospital orders, interpretation of laboratory or other medical diagnostic studies and observations, review of activity therapy reports, supervision of nursing and ancillary personnel, and the programming of all hospital resources for diagnosis and treatment. Some patients receive hospital care services only and others receive hospital care services and other procedures. If other procedures such as electroconvulsive therapy or medical psychotherapy are rendered, these should be listed separately.

   

Unit

Basic

   

Value

Anes:

90803

Psychotherapy, adult or child (verbal

   
 

and/or play therapy, with or without drug

   
 

management), 45-50 minutes, office

16.0

 

90805

home

17.5

 

90806

25 minutes, office

9.7

 

90808

home

10.0

 

90811

15 minutes, office

6.4

 

90813

home

7.3

 

90815

Group therapy (maximum 8 persons per

   
 

group), per person; per session, 45-50

   
 

minutes, office

4.0

 

90817

90 minutes, office

6.4

 

90821

Group therapy (maximum 16 persons

   
 

per group), per person, per session, 45-

   
 

50 minutes, office

3.2

 

90823

90 minutes, office

4.8

 

90835

Narcosynthesis for psychiatric

   
 

diagnostic and therapeutic purposes,

   
 

e.g. sodium amobarbital (Amytal)

   
 

interview

20.5

 

90836

Convulsive therapy, in-patient

14.0

3.0

90838

out-patient

14.0

3.0

90840

Psychologic testing, psychometric and/

   
 

or projective tests, with written report,

   
 

given by or under supervision of

   
 

physician, per hour (identify test(s) used)

18.5

 

90860

Marathon therapy

BR

 

90870

Crisis intervention

BR

 

90875

Hypnotherapy, 45-50 minutes

16.0

 

90876

25 minutes

9.7

 

90877

15 minutes

6.4

 

90880

Sleep therapy, drug induced

BR

 

90885

electrically induced

BR

 

90899

Unlisted psychiatric procedure

BR

 

BIOFEEDBACK

Administration of biofeedback treatment is limited to qualified physicians. Those wishing to administer such treatments to patients covered by the provisions of the Workers' Compensation Law for the conditions listed below should submit evidence of their training and experience to the insurance carrier to expedite processing. Biofeedback treatments may be administered only for the following conditions:

(a) Idiopathic Raynaud's disease

(b) Temporomandibular Joint Dysfunction

(c) Myofascial Pain Dysfunction Syndrome (MPD)

(d) Tension headaches

(e) Migraine headaches

(f) Tinnitus

(g) Torticollis

(h) Neuromuscular re-education as result of neurological damage in CVA or spinal cord injury

(i) Inflammatory and/or musculoskeletal disorders usually related to the accepted condition.

Up to twelve Biofeedback treatments in a ninety day period may be allowed for the above conditions when the following is presented and authorization granted:

(a) An evaluation report documenting:

(i) The basis for the claimant's condition;

(ii) The condition's relationship to the industrial injury or illness;

(iii) An evaluation of the claimant's current functional measurable modalities (i.e., range of motion, up time, walking tolerance, medication intake, etc.);

(iv) An outline of the proposed treatment program;

(v) An outline of the expected restoration goals.

(b) No further Biofeedback treatments will be authorized or paid for without substantiation of evidence of improvement in measurable, functional modalities (i.e., range of motion, up time, walking tolerance, medication intake, etc.). The need for additional treatments will be determined on a case by case review in accordance with Workers' Compensation Board practices. The fees include interpretations and reports of the treatments.

When more than one of the treatments are performed on the same day, the maximum payment will be limited to 8.0 units.

   

Unit

 

Value

 

90900

Biofeedback training by electromyogram

 
 

application - separate procedure (one-half hour)

5.0

90901

Biofeedback training, by electromyogram

 
 

application, including office visit (one-hour)

8.0

90902

In conduction disorder-separate procedure (one-

 
 

half hour)

5.0

90903

In conduction disorder, including office visit (one

 
 

hour)

8.0

90904

Regulation of blood pressure-separate

 
 

procedure (one-half hour)

5.0

90905

Regulation of blood pressure, including office

 
 

visit (one hour)

8.0

90906

Regulation of skin temperature or peripheral

 
 

blood flow-separate procedure (one-half hour)

5.0

90907

Regulation of skin temperature or peripheral

 
 

blood flow, including office visit (one hour)

8.0

90908

By electroencephalogram application - separate

 
 

procedure (one-half hour)

5.0

90909

By electroencephalogram application, including

 
 

office visit (one hour)

8.0

90910

By electro-oculogram application - separate

 
 

procedure (one-half. hour)

5.0

90911

By electro-oculogram application, including

 
 

office visit (.one hour)

8.0

MONITORING SERVICES

(For fetal monitoring during labor, see 59050)

The following values are for physician's services only and do not include charges for use of equipment or supplies where such charges are justified. The values apply only when the physician is engaged solely and is continuously present in the monitoring process.

   

Unit

   

Value

90919

Assembly and operation of pump with

 
 

oxygenator or heat exchanger (with or without

 
 

ECG and/or pressure monitoring), per hour

19.0

90920

Monitoring ECG, pressures, etc., in intrathoracic

 
 

or other critical surgery, per hour (independent

 
 

procedure)

16.0

DIALYSIS

The following descriptors apply only when these services are under the direct supervision of a physician and reflect only the professional component. Supplies, materials, and services of other personnel should be identified separately. If hemodialysis for acute renal failure exceeds six weeks, a further report is required. Detention time may be allowed in addition for highly complicated or unusual or extended hemodialysis if substantiated by report. If other significant, identifiable services are provided in addition to the appropriate hemodialysis procedure, list the appropriate visit for that service.

Peritoneal Dialysis

   

unit

   

Value

90962

Acute renal failure and/or intoxication, including

 
 

cannula insertion and institution of treatment

 
 

program, per dialysis

80.0

90963

excluding cannula and/or catheter insertion,

 
 

per dialysis

30.0

90964

Chronic renal failure, cannula and/or catheter

 
 

insertion, per dialysis

80.0

90965

excluding cannula and/or catheter insertions

 
 

with dialysis through a permanent indwelling

 
 

peritoneal catheter, per dialysis

30.0

Hemodialysis

 
 

(Each of the following code numbers (90970-

   
 

90981) is for a single therapeutic hemodialysis

   
 

treatment.)

   
   

Unit

 
   

Value

 

90970

Acute renal failure and/or intoxication, initial

   
 

hemodialysis

130.0

 

90971

second hemodialysis

80.0

 

90972

third hemodialysis

80.0

 

90973

fourth hemodialysis through end of second

   
 

week, per treatment

40.0

 

90974

third through end of sixth

   
 

week, per treatment. 20.0

   
       
 

(For cannula declotting, see 36860-36861)

   
       

90980

Chronic renal failure, initial stabilization

   
 

through sixth treatment, per treatment

80.0

 

90981

seventh stabilization through end of first month

   
 

of chronic hemodialysis

   
 

therapy, per treatment 30.0

   

90982

Hemodialysis service for a hospitalized chronic

   
 

renal failure patient who

   
 

is hospitalized because

   
 

of an inter-current illness or for a problem

   
 

related or unrelated to chronic renal failure

30.0

 

90983

Hemodialysis treatment per month, two

   
 

treatments per week

120.0

 

90984

three treatments per week

180.0

 

PHYSICAL THERAPY

The procedure codes listed in this section apply only to services rendered by a self-employed duly licensed and registered physical therapist (PT) unless otherwise stated. Physicians rendering physical therapy should utilize the appropriate codes in the Medicine Section.

The relative values listed in this section have been determined on an entirely different basis than those in other sections. A conversion factor applicable to this Section is not applicable to any other section.

The unit values listed in this section reflect the relativity for procedures within this section only.

The fee for a particular procedure or service in this section is determined by multiplying the listed "unit value" by the current dollar "conversion factor" applicable to this section, subject to the Ground Rules, Instructions and Definitions of the Schedule.

Physical Therapists are advised to familiarize themselves with the appropriate Ground Rules listed in the Medicine and Surgery Sections of this Schedule.

PHYSICAL THERAPY

The fees for physical therapy services listed below are payable only when the services are rendered by a self-employed duly licensed and registered physical therapist (PT) unless otherwise stated.

Referral of patients by a physician for the treatment by a PT must be made by means of a referral which may be directive, indicating treatment plan and duration of such treatment. The Physical Therapist shall be responsible for obtaining initial authorization and reauthorization from the carrier after the twelfth physical therapy treatment or after 45 days, whichever comes first, unless previous authorization was for a longer period of time or number of treatments.

The physical therapist shall submit PT-4 reports as required by regulation.

PT's employed by physicians (i.e. not self-employed) may not bill separately from the physician-employer although the latter's billing must indicate the manner of service as delineated above.

When physical therapy is rendered in a hospital department, the hospital shall be entitled to the listed values whether or not the head of the department is C-PMR or PMR coded.

When physical therapists who are self-employed render physical therapy during the after care periods for fractures, dislocations or other post-operative procedures, fees for such treatments shall be in addition to those payable to the referring physician or physician for the after care period, notwithstanding that one or more physicians are also treating the same patient during said after-care period. The referring physician or the physical therapist must inform the employer or carrier of the need for such additional therapy and obtain authorization for such from the employer or carrier. If such authorization is refused, a determination by the Workers' Compensation Board shall be requested. The refusal of such requested authorization shall be appealable in accordance with the Workers' Compensation Law.

When it is necessary to render physical therapy in a patient's home, add 50% to the listed unit value. An explanation justifying the need for home therapy rather than in an office or out-patient hospital setting shall be submitted along with the bill.

When multiple services or procedures (different code numbers) are rendered or performed on one day, the payments will be limited to the greatest allowable fee plus one-half of the lesser fee(s) up to a maximum of twice the highest fee.

ELECTROMYOGRAPHY:

     
   

Unit

   

Value

 

(See codes 95860-95869 and addendum

 
 

thereto).

 

T95860

Electromyography, one extremity and related

 
 

paraspinal areas

12.0

T95861

two extremities and related paraspinal areas

21.6

T95863

three extremities and related paraspinal areas

26.4

195864

four extremities and related paraspinal areas

31.2

T95867

cranial nerve supplied muscles, unilateral

15.6

T95868

bilateral

23.4

T95869

Limited study of specific muscles, e.g., external

 
 

anal sphincter, thoracic spinal muscles, etc

12.0

MODALITIES

Codes 97000 through 97201 apply whether treatment is rendered

to one or more areas on any one day. List Modalities used.

     
   

Unit

   

Value

T97000

Office visit with one or more of the following

 
 

modalities initial 30 minutes

3.0

     
 

a. Hot or cold packs

 
 

b. Traction, mechanical

 
 

c. Electrical stimulation

 
 

d. Vasopneumatic devices

 
 

e. Paraffin bath

 
 

f. Microwave

 
 

g. Whirlpool

 
 

h. Diathermy

 
 

i. Infrared

 
 

j. Ultraviolet

 
 

k. Other (identify)

 
     

T97001

maximum additional1.1

 

PHYSICAL THERAPY

(T97100-T97799)

PROCEDURES

Physical therapist is required to be in constant attendance

     
   

Unit

   

Value

     

T97100

Office visit with one or more of the following

 
 

procedures, initial 30 minutes

3.8

     
 

a. Therapeutic exercises

 
 

b. Neuromuscular re-education

 
 

c. Functional activities

 
 

d. Gait training

 
 

e. Electrical stimulation (manual)

 
 

f. lontophoresis

 
 

g. Traction, manual

 
 

h. Massage

 
 

i. Contrast baths

 
 

j. Isokinetic or Isometric exercises (eg. Cybex)

 
 

k. Ultrasound

 
 

l. Laser

 
 

m. Other (identify)

 
     

T97101

maximum additional

1.8

T97200

Office visit including combination of any

 
 

modality (ies) and procedures(s) initial 30

 
 

minutes

4.7

T97201

maximum additional

1.7

T97220

Hubbard tank, initial 30 minutes

5.4

T97221

each additional 15 minutes (maximum

 
 

allowance, one hour)

1.1

197240

Pool therapy or Hubbard tank with therapeutic

 
 

exercises initial 30 minutes

6.6

T97241

each additional 15 minutes (maximum

 
 

allowance, one hour)

1.4

     
     

T97500

Orthotics training

 
 

(dynamic bracing, splinting

4.5

 

etc) initial 30 minutes

 

T97501

each additional

 
 

15 minutes (maximum

 
 

allowance, one hour)

0.9

197520

Prosthetic training, initial 30 minutes

4.5

 

allowance, one hour)

 

T97521

each additional 15 minutes (maximum

 
 

allowance, one hour)

1.7

197540

Activities of daily

 
 

with adequate report to be submitted (initial and

 
 

separate procedure)

4.5

T97541

each additional 15 minutes (maximum

 
 

allowance, one hour)

1.3

 

(For subsequent ADL training, use code

 
 

T97100)

 
 

(For muscle testing, manual or electrical, joint

 
 

range of motion, electromyography or nerve

 
 

velocity determination, use 95842 et seq)

 

T97700

Office visit, including one of the following tests

 
 

or measurements, with adequate report

 
 

a. Orthotic "check-out"

 
 

b. Prosthetic "check-out"

 
 

c. Activities of daily living "check-out"

 
 

initial 30 minutes

6.8

T97101

each additional 15 minutes

1.9

197702

maximum allowance

9.8

 

machine) initial testing

7.3

T97752

Muscle testing, torque curves during isometric

 
 

and isokinetic exercise (eg. by use of Cybex

 

T97753

subsequent retesting

5.3

 

(applicable only after suitable period of therapy

 

T97799

Unlisted physical therapy service or procedure.

BR

OCCUPATIONAL THERAPY

The procedure codes listed in this section apply only to services rendered by a self-employed duly licensed and registered Occupational Therapist (OT). Physicians rendering occupational therapy should utilize the appropriate codes in the Medicine Section.

The relative values listed in this section have been determined on an entirely different basis than those in other sections. A conversion factor applicable to this Section is not applicable to any other section.

The fee for a particular procedure or service in this section is determined by multiplying the listed "unit value" by the current dollar "conversion factor" applicable to this section, subject to the Ground Rules, Instructions and Definitions of the Schedule.

Occupational Therapists are advised to familiarize themselves with the appropriate Ground Rules listed in the Medicine and Surgery Sections of this Schedule.

AUDITORY SYSTEM

EXTERNAL EAR

(For diagnostic services, such as

audiometric, vestibular and

speech tests, see 92551 et seq)

         

INCISION

   

Unit

Follow-up

Basic

   

Value

Days

Anes:

*69000

Drainage, external ear, abscess

     
 

or hematoma

*0.25

0

4

*69020

Drainage, external auditory

     
 

canal, abscess

*0.25

0

4

69350

Otoscopy, under general

     
         

EXCISION

       

69100

Biopsy, external ear

0.45

0

4

69105

Biopsy, external auditory canal

0.45

0

4

69110

Excision, external ear,

1.9

30

4

 

partial

     

69120

complete amputation

5.1

90

4

 

(For reconstructive of ear, see

     
 

15100 et seq., bone and cartilage

     
 

grafts)

     

69140

Excision, exostosis(es), external

     
 

auditory canal

7.7

90

4

69145

Excision, soft tissue lesion,

     
 

external auditory canal

0.35

30

4

69150

Radical excision, external

     
 

auditory canal lesion, without

     
 

neck dissection

14.4

90

4

69155

with neck dissection

19.2

90

6

         
 

(for resection of temporal bone,

     
 

see 69535)

     
 

(For skin grafts and flaps, see

     
 

15000 et seq.)

     
         

REMOVAL, FOREIGN BODY

*69200

Removal, foreign body from

     
 

external auditory canal, without

     
 

general anesthesia

*0.25

0

 

69205

with general anesthesia

1.3

7

4

 

one or both ears (separate

     
 

procedure)

0.25

0

4

         

REPAIR

 

(For suture of wound or injury of

     
 

external ear, see 12011-14062)

     
 

Unit Follow-up Basic

     
 

Value Days Anes:

     

69300

Otoplasty for protruding ear,

     
 

with or without size reduction,

     
 

unilateral

5.8

90

4

69301

bilateral

8.3

90

4

69320

Reconstruction, external auditory

     
 

canal for congenital atresia,

     
 

single stage

BR

 

4

 

(For combination with middle

     
 

ear reconstruction, see 69631 or

     
 

69641)

     
 

(For other reconstructive

     
 

procedures with grafts [skin,

     
 

cartilage, bone], see 13150-

     
 

15730, 21230-21235)

     

OTHER PROCEDURES

         

69350

Otoscopy, under general

     
 

anesthesia

1.3

7

4

69399

Unlisted Procedure on external

     
 

ear

BR

 

4

MIDDLE EAR

INTRODUCTION

69400

Eustachian tube inflation,

     
 

transnasal, with catheterization

0.2

0

4

69401

without catheterization

0.2

0

4

INCISION

*69420

Myringotomy, including

     
 

aspiration and/or eustachian

     
 

tube inflation

*0.35

0

4

*69424

Ventilating tube removal when

     
 

originally inserted by another

     
 

physician, unlateral

*0.35

0

4

*69425

bilateral

*0.45

0

4

*69433

Tympanostomy (requiring

     
 

insertion of ventilating tube)

     
 

local or topical, anesthesia,

     
 

unilateral

*0.65

0

4

*69434

bilateral

*0.9

0

4

69436

general anesthesia, unilateral

2.3

15

4

69437

bilateral

3.2

15

4

69440

Middle ear exploration through

     
 

post auricular or ear canal

     
 

incision

6.4

30

5

 

(For atticotomy, see 69601 et

     
 

seq)

     

EXCISION

69501

Transmastoid antrotomy

6.4

90

5

69502

Mastoidectomy, complete

10.0

90

5

69505

modified radical

13.0

90

5

69511

radical

13.0

90

6

 

(For skin graft, see 15100 et seq.)

     

69530

Petrous apicectomy including

     
 

radical mastoidectomy

20.8

90

5

An error occurred in the processing of a table at this point in the document. Please refer to the table in the online document.

   
 

Basic

 

Anes:

69535

 
 

5

   
   
   
   

69540

4

69550

 
 

4

69552

5

69554

5

REPAIR

 

69601

 
   
 

5

69603

5

69604

5

   
   
   
   
   

69605

5

   
   
   
   

*69610

 
   
   
 

4

69620

 
   
 

4

69631

 
   
   
   
   
 

5

69632

 
   
 

5

69635

 
   
   
   
   
   
 

5

69636

 
 

5

69637

 
   
   
   
 

5

69641

 
   
   
   
   
 

5

69642

 
 

5

69643

 
   
 

5

69644

 
 

5

69645

 
   

69646

 
 

5

69650

5

   
   
 

5

   

69666

5

69667

5

69670

 
 

5

69675

5

OTHER PROCEDURE

 

69700

 
 

4

69720

 
   
 

9

   
   
   

69740

 
   
   
 

5

69745

 
 

5

   
   

69799

5

INNER EAR INCISION

 

69801

 
   
   
   
 

5

RADIOLOGY

Including Nuclear. Medicine and Diagnostic Ultrasound

GROUND RULES

1. GENERAL: Listed values for radiology procedures apply only when these services are performed by or under the supervision of a physician, with CR ratings. The listed values for Nuclear Medicine also apply to those physicians with C-NUM ratings.

Fees for physicians with R ratings shall be three-fourths of fees indicated. Fees payable to qualified specialists (C-rated but other than C-R) for items listed in this section, and within the scope of their specialty, shall be two-thirds of the indicated fees, except that full fees are payable to those physicians who are certified by the American. Board of Neurological Surgery or the American Board of Psychiatry and Neurology as Neurologists, who perform and interpret CT scans for neurological diagnoses. Fees for all other physicians, including those for items outside the scope of their coding, shall be one-half of the indicated values.

Consultations and referrals for diagnostic and therapeutic radiology are to be done only by specialists, with CR & R ratings.

Physicians qualified as general practitioners with the GP ratings, treating patients under their general medical care are permitted to take x-rays, but radiology requiring the use of ingestion or injection of foreign substance, shall be limited to qualified specialists within their specialty and physicians with the R ratings.

2. DUPLICATION OF X-RAYS: Every attempt should be made to minimize the number of x-rays taken. The attending doctor or any other person or institution having possession of x-rays which pertain to the patient that are deemed to be needed for diagnostic or treatment purposes should make these x-rays available upon request.

No payments shall be made for additional x-rays when recent x-rays are available except when supported by adequate information regarding the need to re-x-ray.

The use of photographic media and/or imaging is not reported separately but is considered to be a component of the basic procedure, and shall not merit any additional payment.

3. MULTIPLE DIAGNOSTIC X-RAY PROCEDURES: The following adjustments apply:

a. For two contiguous parts, the charge shall be the greater fee plus 50% of the lesser fee.

b. For two remote parts, the charge shall be the greater fee plus 75% of the lesser fee.

c. For three or more parts, whether contiguous or remote, the charge shall be the greatest fee plus 75% of the total of the lesser fees.

d. Where more than one part is included in a single line item, it shall be charged for as a single line item. Any additional item examined shall be considered under paragraph a, b, or c above, whichever pertains.

e. No charge shall be made for comparative x-rays except when such x-rays are specifically authorized by the carrier or the chairman. Comparative x-rays specifically authorized shall be subject to fees for contiguous and remote parts as provided in this formula (3a-3d).

f. X-Rays of different areas taken on different but proximate dates and related to the injury or problem necessitating the first x-ray studies, and which could have reasonably been performed at one time, shall be subject to rules a through e above.

4. XERORADIOGRAPHY: Imaging performed by this process shall have the identical values listed for conventional x-ray procedures of the same area and views.

5. MULTIPLE SERVICES OTHER THAN DIAGNOSTIC RADIOLOGY: When multiple or bilateral procedures or services are provided at the same session, the highest fee procedure will be reported as listed. The other procedure (s) will be billed for in accordance with Surgery ground rule 5.

6. UNIT VALUES: The total unit value includes professional services plus expenses of personnel, materials, including usual contrast media and drugs, space, equipment and other facilities. Values for injection procedures include all usual pre and post-injection car specifically related to the injection procedure, necessary local anesthesia, placement of needle or catheter, and injection of contrast media. Supplies and materials provided by the physician (e.g. sterile trays, radioisotopes, etc.) over and above those usually included with or necessitated by the services rendered may be charged for separately; in these instances, list items individually on bill. See Medicine ground rule 13.

The total unit value includes the professional component (see PC unit value below) plus the technical component (TC). This value is applicable in any situation in which a single charge is made to include both professional, services and the technical cost of providing that service. Identification of a procedure by its 5-digit code without modifier -26 or -27 indicates that the charge includes both the "professional" and "technical" components.

The PC unit value (professional component unit value) represents the value of the professional radiological services of the physician. This includes examination of the patient, when indicated, performance and/or supervision of the procedure, interpretation and written report of the examination including images, and consultation with the referring physician. This component is applicable in any situation in which the physician submits a charge for these professional services only. It does not include the cost of personnel, materials, space, equipment or other facilities. To identify a charge for professional component, use the 5-digit procedure code followed by modifier -26. (See modifier -26 and rule 15 for use of modifiers.)

When this section of the Schedule is used in connection with a "conversion factor" to establish fees, it must be emphasized that the conversion factor cannot be applied to both the TOTAL UNIT VALUE and the PROFESSIONAL COMPONENT UNIT VALUE. Physicians who determine their fees by application of conversion factors to the unit values in this section must determine a separate factor for TOTAL UNIT VALUE and for PC UNIT VALUE.

The technical component includes the charges for personnel, materials, including usual contrast media and drugs, film or xerograph, space, equipment and other facilities but excludes the cost of radioisotopes. No unit values are listed for the technical component of radiology procedures, since these are institutional charges not billed separately by physicians. To identify a charge for the technical component, use the 5-digit procedure code followed by modifier -27. (See modifier -27 and Rule 15 for use of modifiers). The total cost of a procedure(s) (PC plus TC) cannot exceed the total unit value cost of the procedure(s).

Fees are for a competent diagnosis by image, expert interpretation and opinion. Size and number of films are not relevant except as indicated by minimum number listed for respective procedures.

7. NECESSITY OF SERVICES OR PROCEDURES: When a patient is referred to radiologists or other specialists for services covered in the Radiology Section, they shall evaluate the patient's problem and determine the service(s) or procedure(s) medically necessary. Such evaluations and necessary consultation with the referring physician(s) is an integral part of the professional component unit value and does not merit any additional charges.

8. REPORTS AND CUSTODY OF X-RAYS AND OTHER RECORDED IMAGES: C48 and C4 reports are not acceptable. A written report of the findings must be submitted in quadruplicate; mail one to the district office of the Workers' Compensation Board, one to the attending physician and retain one for your records; the fourth to accompany bill to insurance carrier, if known, or to the employer.

Films or other recorded images shall be preserved for at least six years (but in no case shall they be destroyed without a report of the findings of such images being filed, as a permanent record). They (or satisfactory reproductions) shall be made available to the attending physician, insurance carrier or self-insured employer. When requested, carriers and self-insured employers shall return original films to the physician within 20 days of their receipt.

When a carrier or self-insured employer requests x-rays and satisfactory reproductions are furnished in lieu of the original films, a fee of four dollars ($ 4.00) may be charged for the first sheet of duplicating film and two dollars ($ 2.00) for each additional sheet of film. These reproductions are not returnable to the physician. Copies of images produced by copiers (e.g. Xerox) shall not merit any additional payment and shall not be returnable to the physician; such copies should accompany the bill submitted for the particular, imaging procedure. (The use of photographic media and/or imaging is not reported separately but is considered to be a component of the basic procedure.)

In cases where the patient transfers from one physician to another the former treating physician will promptly forward all images or copies of such to the new attending physician.

9. MATERIALS SUPPLIED BY PHYSICIAN: Supplies and materials provided by the physician (e.g., sterile trays, drugs, etc.) over and above those usually included with the office visit or other services rendered may be charged for separately. (List drugs, trays, materials or supplies provided.) Radiopharmaceutical or other radionuclide material cost: Listed values in this section do not include these costs. List the name and dosage of radiopharmaceutical material and cost (See Medicine ground rule 13.)

10. INJECTION PROCEDURES: Values for injection procedures include all usual pre-and post-injection care specifically related to the injection procedure, necessary local anesthesia, placement of needle or catheter and injection of contrast media.

Vascular injection procedures are listed in the cardiovascular section, under procedure codes 36000-36299. Other injection procedures are listed in appropriate sections.

11. "BR" (BY REPORT) ITEMS: "BR" in the value column (s) indicates that the value of that service is to be determined by report because the service is too unusual, variable or new to be assigned a unit value (s).

Submit a special report describing medical appropriateness of the service. Pertinent information-should include an adequate definition or description of the nature, extent, and need for the procedure and the time, effort, and equipment necessary to provide the service. Additional items which may be helpful might include:

Complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems, and follow-up care.

12. UNLISTED SERVICE OR PROCEDURE: A service or procedure may be provided that is not listed in this Fee Schedule. When reporting such a service, the appropriate "Unlisted Procedure" code may be used to indicate the service, identifying it by report ("BR"). See 11. above.

13. SUBSECTION INFORMATION: Several of the subheadings or subsections have special needs or instructions unique to that section. Where these are indicated, e.g. "Therapeutic Radiology," special "NOTES" will be presented preceding those procedural terminology listings, referring to that subsection specifically. If there is an "Unlisted Procedure" code number (see item 12) for the individual subsection it will be shown. Those subsections with "NOTES" are as follows.

Subsection

Code Numbers

Diagnostic Ultrasound

76500-76999

Therapeutic Radiology

77261-77999

Nuclear Medicine

78000-79999

14. MISCELLANEOUS:

a.) Emergency services rendered between 10 p.m. and 8 a.m. in response to requests received during those hours or on Sundays or legal holidays, provided such services are not otherwise reimbursed, may warrant an additional payment of one-third of the applicable fee. Submit report (See 11 above and Medicine ground rules 7 & 8).

b.) Values for office, home and hospital visits, consultation and other medical services, anesthesia, surgical and laboratory procedures are listed in the sections entitled "Medicine," "Anesthesia," "Surgery," and "Pathology."

15. UNIT VALUE MODIFIERS:

-26 Professional Component: When the professional component unit value only is applicable, identify by adding this modifier (-26) to the usual procedure number(s). Charges shall be in accordance with the "PC Unit Value" for that procedure(s).

-27 Technical Component: When the professional component is charged for separately from the total unit value, the technical component will also be charged for separately. The technical component unit value will be the total value, less the professional component value. Identify by adding this modifier (-27) to the usual procedure(s) code number(s).

See item 6 above for correct conversion factor applicable to -26 and -27.

16. CT SCAN RECONSTRUCTION: (effective September 1, 1989)

An additional fee up to a maximum of $ 100 may be permitted for CT scan reconstruction. This additional fee shall be payable only when the reconstruction is requested by the primary care physician. The request must follow a review of the regular CT scan film and only if there is a specifically stated need for clarification via reconstruction.

The fee for reconstruction must be submitted on a separate bill with a separate report and a copy of the primary care physician's request.

17. MAGNETIC RESONANCE IMAGING: (effective September 1, 1989)

The fees for Magnetic Resonance Imaging shall be as follows: Professional component: 4 Radiology units for an MRI of any one part of the body Technical component: see chart below

 

Region I

Region II

Region III

Region IV

Technical component

$ 611

$ 635

$ 654

$ 670

The fees payable for an MRI study include both standard and axial views.

The provisions of Radiology Ground Rules 1 and 3 apply to Magnetic Resonance Imaging.

DIAGNOSTIC RADIOLOGY

         

HEAD AND NECK

 
         
   

PC Unit

Total Unit

 
   

 Value

 Value

 

70002

Pneumoencephalography, supervision

     
 

and interpretation only

3.3

9.0

 

70003

complete procedure

9.0

15.0

 
         
 

(For injection procedure for

     
 

pneumoencephalography, see 61053,

     
 

62286)

     
         

70010

Myelography, posterior fossa, supervi-

     
 

sion and interpretation only

3.0

7.5

 

70011

complete procedure

5.5

10.0

 
         
 

(For injection procedure only for

     
 

myelography, see 61052)

     
         

70015

Cisternography, positive contrast

     
 

supervision and interpretation

     
 

only

3.0

7.5

 

70016

complete procedure

5.5

10.0

 
         
 

(For injection procedure only for

     
 

cisternography, see 61053)

     
         

70020

Ventriculography, air

     
 

contrast, supervi-

     
 

sion and interpretation only

3.0

7.5

 

70021

positive contrast,

     
 

supervision and

     
 

interpretation only

3.0

7.5

 
         
 

(For injection procedure

     
 

only for

     
 

ventriculography, see

     
 

61025, 61120)

     
         

70022

Stereotactic localization, head

4.0

9.0

 

70030

Eye, for foreign body detection

0.8

2.0

 

70040

for localization of foreign

     
 

body (70030

     
 

not included)

1.5

3.0

 

70050

combined 70030 and 70040

2.0

4.0

 

70100

Mandible, partial, less

     
 

 than four views

0.6

1.5

 

70110

complete, minimum

     
 

of four views

0.8

2.0

 

70120

Mastoids, less than three

     
 

views per side

0.7

1.7

 

70130

complete, minimum of three views per

     
 

side

1.0

2.5

 

70131

Internal auditory meati, complete

1.0

2.5

 

70140

Facial bones, less than three views

0.6

1.5

 

70150

complete, minimum of three views

0.8

2.0

 

70160

Nasal bones, complete, minimum of

     
 

three views

0.6

1.5

 

70170

Dacryocystography, (nasolacrimal duct),

     
 

supervision and interpretation only

0.8

2.0

 

70171

complete procedure

2.3

3.5

 
         
 

(For injection procedure only for

     
 

dacryocystography, see 68850)

     
         

70190

Optic foramina

0.6

1.5

 

70200

Orbits, complete, minimum of four views

0.8

2.0

 

70210

Sinuses, paranasal,

     
 

less than three views

0.6

1.5

 

70220

complete, minimum of three views,

     
 

without contrast studies

0.8

2.0

 

70230

with contrast studies, in addition to

     
 

70220, supervision and interpretation

     
 

only

0.9

2.5

 
         

70231

 with contrast studies, in addition to

     
 

70220, complete procedure

4.8

6.0

 

70240

Sella turcica

0.7

1.7

 

70250

Skull, less than four views, with or

     
 

without stereo

0.6

1.5

 

70260

complete, minimum of four views,

     
 

with or without stereo

1.2

3.0

 

70300

Teeth, single view

0.2

0.5

 

70310

partial examination, less than full

     
 

mouth

0.4

1.0

 

70320

complete full mouth

0.8

2.0

 

70328

Temporomandibular joint, open and

     
 

closed mouth, unilateral

0.6

1.5

 

70330

bilateral

1.0

2.5

 

70332

Temporomandibular joint

     
 

arthrotomography (includes a contrast

     
 

arthrogram and appropriate

     
 

laminographic studies); supervision and

     
 

interpretation only

2.0

4.5

 

70333

complete procedure

4.0

6.5

 
         
 

(For injection procedure only for

     
 

arthrotomography, see 21116)

     
         

70350

Cephalogram, orthodontic

0.4

1.0

 

70355

Orthopantogram

0.4

1.0

 

70360

Neck, soft tissue

0.4

1.0

 

70370

pharynx or larynx, including

     
 

 fluoroscopy and/or magnification

     
 

technique

1.0

2.5

 

70373

Laryngography, contrast, supervision

     
 

and interpretation only

1.2

3.0

 

70374

complete procedure

3.0

4.5

 
         
 

(For injection procedure only for

     
 

laryngography, see 31708)

     
         

70380

Radiologic examination, salivary gland

     
 

for calculus

0.6

1.5

 

70390

Sialography, supervision and

     
 

interpretation only

0.8

2.0

 

70391

complete procedure

2.3

3.5

 
         
 

(For injection procedure only for

     
 

sialography, see 42550)

     
         

70400

Orbitography, all or positive contrast,

     
 

supervision and interpretation only

1.8

4.5

 
         
 

(For injection procedure only for

     
 

orbitography, see 67510)

     
         

70401

complete procedure

5.7

9.0

 

70450

Computerized axial tomography, head,

     
 

without contrast material

4.0

8.5

 

70460

with contrast material(s)

4.0

10.5

 

70470

without intravenous contrast material,

     
 

followed by contrast material(s) and

     
 

further sections

5.0

12.0

 

70480

Computerized axial tomography, orbit,

     
 

sella, or posterior

     
 

fossa or outer, middle,

     
 

or inner ear, without contrast material

4.0

8.5

 
   

PC Unit

Total Unit

   

Value

Value

75718

by serialography, complete procedure.

10.5

16.5

75722

Angiography, renal, unilateral, selective,

   
 

supervision and interpretation only

3.0

12.0

75723

complete procedure

9.6

18.0

75724

Angiography, renal, bilateral, selective

   
 

(including flush aortogram), supervision

   
 

and interpretation only

4.5

13.5

75725

complete procedure

13.2

21.0

75726

Angiography, visceral, selective or

   
 

subselective, supervision and

   
 

interpretation only

3.9

13.5

75727

selective (including flush aortogram),

   
 

complete procedure

11.1

21.0

75728

subselective, complete procedure

13.2

22.5

       
 

(For selective angiography, additional

   
 

visceral vessels, studied after basic

   
 

examination, see 75772, 75773)

   
       

75731

Angiography, adrenal, unilateral,

   
 

selective, supervision and interpretation

   
 

only

3.3

12.0

75732

complete procedure

11.1

19.5

75733

Angiography, adrenal, bilateral selective,

   
 

supervision and interpretation only

4.8

13.5

75734

complete procedure

15.0

22.5

75736

Angiography, pelvic, selective or

   
 

supraselective, supervision and

   
 

interpretation only

3.0

9.0

75737

selective; complete procedure

7.5

13.5

75738

supraselective, complete procedure

9.6

15.0

75741

Angiography, pulmonary, unilateral,

   
 

selective, supervision and interpretation

   
 

only

3.0

9.0

75742

complete procedure

9.6

15.0

75743

Angiography, pulmonary, bilateral,

   
 

selective, supervision and interpretation

   
 

only

4.5

10.5

75744

complete procedure

11.1

18.0

75746

Angiography, pulmonary, by

   
 

nonselective catheter or venous

   
 

injection, supervision and interpretation

   
 

only

3.0

9.0

75747

catheter, nonselective, complete

   
 

procedure

9.0

15.0

75748

venous injection, complete procedure

5.7

12.0

75750

Angiography, coronary, root injection,

   
 

supervision and interpretation only

3.9

12.0

75751

complete procedure

9.6

16.5

75752

Angiography, coronary, unilateral

   
 

selective injection, including left

   
 

ventricular and supravalvular angiogram

   
 

and pressure recording, supervision and

   
 

interpretation only

3.9

15.0

75753

complete procedure

15.0

27.0

75754

Angiography, coronary, bilateral

   
 

selective injection, including left

   
 

ventricular and supravalvular angiogram

   
 

and pressure recording, supervision and

   
 

interpretation only

5.7

21.0

75755

complete procedure

18.9

34.5

75756

Angiography, internal mammary,

   
 

supervision and interpretation only

1.8

9.0

75757

complete procedure

9.6

16.5

75762

Angiography, coronary bypass,

   
 

unilateral selective injection, supervision

   
 

and interpretation only

3.9

15.0

75764

complete procedure

15.0

27.0

75766

Angiography, coronary bypass, multiple

   
 

selective injection, supervision and

   
 

interpretation only

5.7

21.0

75767

complete procedure

18.9

34.5

75772

Angiography, visceral, selective,

   
 

additional vessels studied after basic

   
 

examination, supervision and

   
 

interpretation only

3.5

10.5

75773

complete procedure

8.5

10.5

VEINS AND LYMPHATICS

For injection procedure only for venous system, see 36400-36510) For injection procedure only for lymphatic system, see 38790-38794)

   

PC Unit

Total Unit

   

Value

Value

75801

Lymphangiography, extremity only,

   
 

unilateral, supervision and interpretation

   
 

only

1.8

7.5

75802

complete procedure

7.5

13.5

75803

Lymphangiography, extremity only,

   
 

bilateral, supervision and interpretation

   
 

only

3.0

9.0

75804

complete procedure

9.6

15.0

75805

Lymphangiography, pelvic/abdominal,

   
 

unilateral, supervision and interpretation

   
 

only

2.4

7.5

75806

complete procedure

7.5

13.5

75807

Lymphangiography, pelvic/abdominal,

   
 

bilateral, supervision and interpretation

   
 

only

3.3

9.0

75808

complete procedure

10.2

15.0

75810

Splenoportography, supervision and

   
 

interpretation only

1.8

7.5

75811

complete procedure

7.5

13.5

75820

Venography, extremity, unilateral,

   
 

supervision and interpretation only

1.5

4.5

75821

complete procedure

3.9

6.5

75822

Venography, extremity, bilateral,

   
 

supervision and interpretation only

1.2

6.0

75823

complete procedure

5.7

9.0

75825

Venography, caval, inferior with

   
 

serialography, supervision and

   
 

interpretation only

1.8

6.0

75826

complete procedure

5.7

9.0

75827

Venography, caval, superior, with

   
 

serialography, supervision and

   
 

interpretation only

1.8

6.0

75828

complete procedure

5.7

9.0

75831

Venography, renal, unilateral, selective,

   
 

supervision and interpretation only

2.7

6.5

75832

complete procedure

6.3

10.5

75833

Venography, renal, bilateral, selective,

   
 

supervision and interpretation only

4.2

7.5

75834

complete procedure

9.6

13.5

75840

Venography, adrenal, unilateral,

   
 

selective, supervision and interpretation

   
 

only

2.7

6.5

75841

complete procedure

7.5

12.0

75842

bilateral, selective, supervision and

   
 

interpretation only

4.2

7.5

75843

complete procedure

13.2

18.0

75845

Venography, azygos, selective or

   
 

nonselective, supervision and

   
 

interpretation only

2.4

6.0

   

PC Unit

Total Unit

 
   

Value

Value

 

75846

selective, complete procedure

7.5

12.0

 

75847

non-selective, complete procedure

6.3

10.5

 

75850

Venography, intraosseous, supervision

     
 

and interpretation only

2.4

6.0

 

75851

complete procedure

5.7

9.0

 

75860

Venography, sinus or jugular, catheter,

     
 

supervision and interpretation only

3.9

9.0

 

75861

complete procedure

9.6

14.5

 

75870

Venography, superior sagittal sinus,

     
 

supervision and interpretation only

3.0

7.5

 

75871

direct puncture, complete procedure

7.5

12.0

 

75880

Venography, orbital, supervision and

     
 

interpretation only

1.8

6.0

 

75881

complete procedure

5.7

10.0

 

75885

Percutaneous transhepatic potography

     
 

with hemodynamic evaluation,

     
 

supervision and interpretation only

3.0

8.5

 

75886

complete procedure

10.5

15.0

 

75887

Percutaneous transhepatic portography

     
 

without hemodynamic evaluation,

     
 

supervision and interpretation only

2.9

8.4

 

75888

complete procedure

10.0

14.5

 

75889

Hepatic venography, wedged or free,

     
 

with hemodynamic evaluation,

     
 

supervision and interpretation only

3.5

10.4

 

75890

complete procedure

8.5

10.5

 

75891

Hepatic venograph, wedged or free

     
 

without hemodynamic evaluation,

     
 

supervision and interpretation only

3.4

10.3

 

75892

complete procedure

8.4

10.4

 

75893

Venous sampling through catheter

     
 

without angiography (eg. for parathyroid

     
 

hormone, renin)

10.

15.0

 

TRANSCATHETER THERAPY AND BIOPSY

   

PC Unit

Total Unit

   

Value

Value

75894

Transcatheter therapy, embolization,

   
 

including angiography, supervision and

   
 

interpretation only

3.5

18.4

75895

complete procedure

10.5

15.0

75896

Transcatheter therapy, infusion,

   
 

including angiography, supervision and

   
 

interpretation only

3.5

10.4

75897

complete procedure

10.5

15.0

75898

Angiogram through existing catheter for

   
 

follow-up study for transcatheter

   
 

therapy, embolization or infusion

3.5

10.5

75950

Transcatheter, intravascular occlusion,

   
 

temporary; supervision and

   
 

interpretation only

3.5

10.4

75951

complete procedure

10.5

15.0

75955

Transcatheter intravascular occlusion,

   
 

permanent, supervision and

   
 

interpretation only

3.5

10.5

75956

complete procedure

10.5

15.0

75961

Transcatheter retrieval, percutaneous, of

   
 

fractured venous or arterial catheter

10.0

12.0

75970

Transcatheter biopsy, supervision and

   
 

interpretation only

3.0

7.5

75971

complete procedure

9.5

12.5

 

(For transcatheter renal and ureteral

   
 

biopsy, see 52007, 52107)

   
 

(For percutaneous needle biopsy of

   
 

pancreas, see 48102; of retroperitoneal

   
 

lymph node or mass, see 49180)

   

75972

Percutaneous transluminal angioplasty,

   
 

unilateral, supervision and interpretation

   
 

only

6.5

13.5

75973

complete procedure

30.0

37.0

75974

Percutaneous transluminal angioplasty,

   
 

bilateral, single catheter, supervision and

   
 

interpretation only

8.5

15.0

75975

complete procedure

35.0

38.0

75976

Percutaneous transluminal angioplasty,

   
 

bilateral, dual catheters, supervision and

   
 

interpretation only

8.5

15.0

75977

complete procedure

35.0

38.0

75980

Percutaneous transhepatic biliary

   
 

drainage with contrast monitoring,

   
 

supervision and interpretation only

3.0

7.5

75981

complete procedure

30.0

37.5

75982

Percutaneous placement of drainage

   
 

catheter for combined internal and

   
 

external biliary drainage or of a drainage

   
 

stent for internal biliary drainage in

   
 

patients with an inoperable mechanical

   
 

biliary obstruction, supervision and

   
 

interpretation only

4.5

9.5

75983

complete procedure

30.0

37.5

75985

Change of percutaneous drainage

   
 

catheter with contrast monitoring (ie.

   
 

biliary tract, urinary tract) complete

   
 

procedure

3.0

7.5

       
 

(For injection procedure only for

   
 

percutaneous biliary drainage, see

   
 

47510)

   
       

75990

Drainage of abscess, percutaneous, with

   
 

radiologic guidance (ie. fluoroscopy,

   
 

ultrasound or computerized

   
 

tomography) with or without placement

   
 

of indwelling catheter

8.5

15.0

       
 

(75990 is neither organ nor area specific.

   
 

For drainage of abscess performed

   
 

without radiology or fluoroscopy, see

   
 

under specific anatomic site.)

   

MISCELLANEOUS

(For arthrography of shoulder, see 73040, 73041; elbow, see 73085, 73086; wrist, see 73115, 73116; hip, see 73525, 73526, knee, see 73580, 73581; ankle, see 73615, 73616)

   

PC Unit

Total Unit

 
   

Value

Value

 

76000

Fluoroscopy, (separate procedure) other

     
 

than 71034

1.3

0

 

76020

Bone age studies

0.6

1.5

 

76040

Bone length studies

     
 

(orthoroentgenogram, scanogram)

1.0

2.5

 

76061

Radiologic examination, osseous survey,

     
 

limited (eg. for metastases)

2.0

4.5

 

76062

complete (axial and appendicular.

     
 

skeleton)

BR

BR

 

76065

infant

0.8

2.0

 

76080

Radiologic examination, fistula or sinus

     
 

tract study, supervision and

     
 

interpretation only

1.0

2.5

 

76081

complete procedure

2.5

4.0

 
   

PC Unit

Total Unit

   

Value

Value

76086

Mammary ductogram or galactogram,

   
 

unilateral, supervision and interpretation

   
 

only

1.0

2.5

76087

complete procedure

1.5

3.5

76088

Mammary ductogram or galactogram,

   
 

bilateral, supervision and interpretation

   
 

only

1.0

2.5

76089

complete procedure

1.5

3.5

 

(For injection procedure only for

   
 

mammary ductogram or galactogram,

   
 

see 19030)

   
       

76090

Mammography, unilateral

1.0

2.5

76091

bilateral

1.5

3.5

76094

Radiologic examination, localization of

   
 

breast nodule or calcification before

   
 

operation, with marker and confirmation

   
 

of its position with appropriate imaging

2.4

4.0

76100

Radiologic examination, single plane

   
 

body section (eg. tomography,

   
 

planigraphy, body section radiography)

   
 

(Separate procedure)

2.0

2.8

76120

Cineradiography, except where

   
 

specifically included

1.1

2.8

76125

Cineradiography, to complement routine

   
 

examination

0.6

1.5

76400

Magnetic Resonance: bone marrow

   
 

blood supply....See page 159

   

76499

Unlisted diagnostic, radiologic

   
 

procedure

BR

BR

DIAGNOSTIC ULTRASOUND

NOTES

A-mode implies a one-dimensional ultrasonic measurement procedure. M-mode implies a one-dimensional ultrasonic measurement procedure with movement of the trace to record amplitude and velocity of moving echo-producing structures. B-scan implies a two-dimensional ultrasonic scanning procedure with a two-dimensional display. Real-time scan implies a two-dimensional ultrasonic scanning procedure with display of both two-dimensional structure and motion with time.

HEAD AND NECK

   

PC Unit

Total Unit

   

Value

Value

76500

Echoencephalography, A-mode,

   
 

diencephalic midline

1.0

2.0

76505

complete (diencephalic midline and

   
 

ventricular size)

1.5

3.0

76506

Echoencephalography, B-mode, (gray

   
 

scale) complete (for determination of

   
 

ventricular size, delineation of cerebral

   
 

contents and detection of fluid, masses

   
 

or other intracranial abnormalities),

   
 

including A-mode encephalography as

   
 

secondary component where indicated

BR

BR

76511

Echography, ophthalmic, spectral

   
 

analysis with amplitude quantitation, A-

   
 

mode

1.9

3.8

76512

contract B-scan

1.9

3.8

76515

tomography with or without A or M-

   
 

mode

2.8

5.6

76516

Echography, ophthalmic, ultrasonic

   
 

biometry, A-mode

1.3

2.6

76517

B-scan

2.8

5.6

76529

Ophthalmic ultrasonic, foreign body

   
 

localization

BR

BR

76530

Echography, thyroid, A-mode

1.0

2.0

76535

B-scan

1.5

3.0

76550

Carotid imaging

1.5

3.0

       
 

(For Doppler, see 76900)

   

CHEST

   

PC Unit

Total Unit

   

Value

Value

76601

Echography, chest, A-mode

1.2

2.5

76604

B-scan (includes mediastinum)

1.5

3.0

76620

Echocardiography, M-mode complete

1.5

4.0

76625

limited (eg. follow-up or limited

   
 

studies)

1.0

2.0

76627

Echocardiography, real-time scan,

   
 

complete (includes 76620)

4.0

5.6

76628

limited

3.2

4.5

       
 

(For echocardiography as a

   
 

cardiovascular procedure, see 76620-

   
 

76625)

   
       

76640

Echography, breast, A-mode

1.2

2.5

76645

B-scan

2.5

5.0

ABDOMEN AND RETROPERITONEUM

   

PC Unit

Total Unit

   

Value

Value

76700

Echography, abdominal, B-scan,

   
 

complete

3.0

6.0

76705

limited (eg. follow-up or limited

   
 

studies)

2.0

4.0

76770

Echography, retroperitoneal (eg. renal,

   
 

aorta, nodes), B-scan, complete

2.5

5.0

76775

limited

1.8

3.5

PELVIS

   

PC Unit

Total Unit

   

Value

Value

76805

Echography, pelvic, B-scan (eg. real-

   
 

time) in obstetrics, gynecology or

   
 

transplants, complete

2.0

4.0

76815

limited (fetal growth rate, heart beat,

   
 

anomalies, placental location)

1.5

3.0

GENITALIA

   

PC Unit

Total Unit

   

Value

Value

76870

Echography, scrotum and contents

2.0

4.0

EXTREMITIES

   

PC Unit

Total Unit

   

Value

Value

76880

Echography, extremity, B-scan

1.5

3.0

VASCULAR STUDIES

   

PC Unit

Total Unit

   

Value

Value

76900

Peripheral flow study (Doppler), arterial

   
 

only

1.5

3.0

76910

venous only

1.5

3.0

76920

arterial and venous

2.3

4.5

76925

Peripheral imaging, B-scan, Doppler or

   
 

real-time scan

1.5

3.0

Magnetic Resonance Imaging

   

abdomen

74181

 

bone marrow blood supply

76400

 

brain, including brain stem

70551

 

chest

71550

 

lower extremity

73720

 

myocardium

75552

 

orbit, face and neck

70540

 

pelvis

72196

 

spinal canal and contents; cervical

72141

 

spinal canal and contents; lumbar

72144

 

spinal canal and contents; thoracic

72143

 

upper extremity

73220